Pharmaceutical composition for the treatment of autoimmune diseases

ABSTRACT

PCT No. PCT/EP96/04672 Sec. 371 Date Sep. 3, 1998 Sec. 102(e) Date Sep. 3, 1998 PCT Filed Oct. 26, 1996 PCT Pub. No. WO97/16185 PCT Pub. Date May 9, 1997A pharmaceutical composition comprising an anti-inflammatory drug capable of suppressing the production of cytokines (CSAID) an immunosuppressant and a pharmaceutically acceptable excipient.

This application is a 371 of PCT/EP96/04672 filed Oct. 26, 1996, andclaims the benefit of Italian application MI 95A002242 filed Oct. 31,1995.

The present invention relates to a pharmaceutical composition comprisingan 2-((1-benayl-indazol-3-yl)-methoxy)-2-methyl propionic acid(bindarit), an immunosuppressant and a pharmaceutically acceptableexcipient.

It is known that the autoimmune diseases form a wide group ofpathologies characterized by inflammatory phenomena and destruction oftissues caused by the production, by the immune system, of body's ownantibodies. Examples of diseases considered to be autoimmune in natureare: rheumatoid arthritis, glomerulonephritis, Hashimoto's thyroiditis,systemic lupus erythematosus, myasthenia gravis, autoimmune hemolyticanemia, autoimmune thrombocytopenic purpura, autoimmune disorders andtype 1 diabetes.

Presently, in the autoimmune diseases therapy there are used steroidaland non-steroidal anti-inflammatory drugs, gold compounds, penicillinsand immunosuppressants.

Non-steroidal anti-inflammatory drugs (NSAID) show, together with theanti-inflammatory activity, also an antipyretic and a non-narcoticanalgesic effect. They are widly used both in the acute inflammatorytherapy and in chronic inflammatory treatment. For this reason they arecurrently used in the treatment of autoimmune pathologies, wherein theinflammatory process is often very important. Even if other mechanismsof action may not be excluded, their activity is mainly due to thecapability of inhibiting the enzymes responsible for prostaglandins (PG)and leucotriens synthesis, in particular cyclooxygenases andlipooxygenases. This mechanism of action is mostly responsible also forside effects on different organs (mainly gastrointestinal and renal)that occur as a consequence of the prolonged use of said drugs.

Further, to the mainly symptomatic effects that are obtained by theanti-inflammatory drugs in the acute phase of autoimmune pathologies,the most important therapeutical effects are obtained by non-steroidaldrugs such as, for example, cyclophosphamide.

However, this kind of drug can not be administered for prolonged periodsof time because of the onset of different type of side effects havingconsiderable side effects.

In fact, that treatment must be stopped because of the onset of toxicityon organs or of systemic nature in more than 20% of patients within 12months. The remission phases last for a very variable period of time(from 1 to 18 months on average) and, although a second and often athird therapy cycle may give positive results, more than 50% of patientsthat initially responded to the therapy must stop it after 3-6 yearsbecause of relapses and/or because of the late toxicity. The organs thatare most frequently involved are kidneys, liver, blood and reproductiveapparatus.

Therefore, toxic effects of therapies employed in autoimmune phatologiesare a serious obstacle to their use and thus there is a serious need ofa product capable of reducing the undesired side effects of drugsemployed in said therapies, thus reducing the doses or the number ofadministrations.

Now, it has been unexpectatebly found that bindarit (1) allows reducingthe immunosuppressants dose in the prolonged treatment of autoimmunediseases, without reducing the therapeutical efficacy thus improving thetolerability.

Therefore, it is a first object of the present invention to provide apharmaceutical composition comprising bindarit an immunosuppressant anda pharmaceutically acceptable excipient.

Further, it is a second object of the present invention to provide amethod of treating autoimmune diseases characterized by the concurrentadministration bindarit and an immunosuppressant.

Typical examples of immunosuppressants according to the presentinvention are: cyclosporin, azatioprin, methotrexate, cyclophsphamide,FK 506, cortisol, betametasone, cortisone, desametasone, flunisolide,prednisolone, methylprednisolone, prednisone, triamcinolone,alclometasone, amcinonide desonide and desoxymetasone.

Typical examples of diseases that can benefit from the concurrenttreatment with bindarit and an immunosuppressant are: rehumatoidarthritis, glomerulonephritis, Hashimoto's thyroiditis, systemic lupuserythematosus, myasthenia gravis, autoimmune hemolytic anemia,autoimmune thrombocytopenic purpura, autoimmune hepatitis, type 1diabetes and similar.

The amount of bindarit will range depending on factors which are wellknown to the person skilled in the art such as, for example, the type ofautoimmune disease, the severity of said disease, the body weight of thepatient, the pharmaceutical dosage form, the route of administration,the number of dosage forms administred daily and the efficacy of theused compounds. However, the optimum amount may be easly determined byroutine procedures of "dose-finding".

Generally, the amount of bindarit will be of from 1 to 50 mg/Kg/day.More preferably, it will be of from 4 to 35 mg/Kg/day.

Also the amount of the immunosuppressant drug will range depending onfactors well known to the person skilled in the art such as, forexample, the type of autoimmune disease, the severity of said disease,the body weight of the patient, the pharmaceutical dosage form, theroute of administration, the number of dosage forms administred dailyand the efficacy of the used compounds. However, the optimum amount maybe easly determined by routine procedures particularly considering thatthe usual dosages of immunosuppressants are known in the literature(Goodman and Gilman 8th ed.).

Generally, the amount of the immunosuppressant drug will be such that itinsures an administration level of from 0.01 to 100 mg/Kg/day.

For example, in the particular case of cyclophosphamide it will be about30-40% lower compared to the usual one. Therefore, it will prefearablybe of from 0.01 to 10 mg/Kg/day. More preferably, it will be of from0.05 to 5 mg/Kg/day.

In its turn, in the case of prednisone, said amount will be also 30-40%lower compared to the usual one. Therefore, it will preferably be offrom 0.01 to 1 mg/Kg/day. More preferably, it will be of from 0.05 to0.5 mg/Kg/day.

Example of suitable dosage forms are tablets, capsules, coated tablets,granules, solutions and syrups for oral administration, gels, ointments,creams and medicated patches for topic administration, suppositories forrectal administration and sterile solutions for injectable, aerosolicand ophthalmic administration.

In addition to usual excipients, the compositions may comprise suitableadditives for pharmaceutical use such as preservatives, stabilizers,surface active agents, emulsifiers, salts for the regulation of theosmotic pressure, buffers, flavouring agents and colouring agents.

They may also comprise liposomes, vesicles and other forms useful toobtain a controlled release of pharmacologically active compounds.Further, they can be formulated in form of stratified tablets containinglayers which have a different speed of disintegration.

If particular treatments require it, the compositions of the presentinvention may comprise other compatible active ingredients whoseconcurrent administration is therapeutically useful.

The pharmaceutical compositions can be producted according toconventional techniques of the pharmaceutical chemist comprising mixing,granulating and compressing, when needed, or various mixings anddissolutions of the ingredients, depending on what is appropriate forobtaining the desired compound.

EXPERIMENTS

1. Bindarit Effects on Cytokines

Bindarit effect on the production of inflammatory cytokines has beenevaluated in a mouse model wherein, after administration ofconcanavaline A (0.3 microg/mouse i.v.), there have been measured serumlevels of interleukine-6 (IL-6) both in control animals and in animalstreated with 200 mg/Kg of bindarit orally. The experiment results(Table 1) show that in the animals receiving bindarit, the IL-6 serumlevels are about 40% lower compared to the untreated controls (10.2±2.1vs. 16.5±6.4 nanogram/ml; 6 animals in each group).

Bindarit capability to reduce the inflammatory cytokines productionallows to count this product among CSAID drugs, being already known thatbindarit is devoid immunosuppressive activity and that it is not activeon cyclooxygenase and lipooxygenase (2).

2. Bindarit and Cyclohosphamide in a Mouse Model of Lupus Erythematosus.

NZB/W F1 hybrid mice spontaneously generate an autoimmune pathologywhich is clinically and immunologically similar to human lupussystematic erythematosus (SLE). This mouse model of SLE appears to behighly predictive and it is generally used as a preclinic model forstudying new ways of treatment. Drugs conventionally used in humantherapy are, in fact, active in this animal model, characterized by asubstantial proteinuria, by the presence of autoantibodies andcirculating immunocomplexes and by the growth of glomerulonephritis,that in these animals is the main cause of death. Immunosuppressantssuch as cyclophosphamide and prednisone are capable of delaying thepatology progress, however their therapeutic potential is limited bytheir general toxicity and by the high neoplasia incidence and viralinfections resulting from their use.

Bindarit, administrated to NZB/W F1 female mice (26 each group) asmedicated diet at 0.5%, which produces hematic levels of bindarit offrom 50 to 200 micrograms/ml (determined by inverse phase HPLC),together with cyclophosphamide bola at low doses (2×22.5 and 2×45 mg/Kgip) proved to be capable of insuring an activity comparable to thatobtained at high doses of cyclophosphamide thus favouring a decrease oftoxicity phenomena associated to the immunosuppressive therapy. Thetreatment with bindarit together with cyclophosphamide, in fact, hassignificantly prolonged the life of the animals (Table 2) and it hasfurther strengthened the effects of cyclophosphamide on theimmunological parameters typical of this model (Table 3) improvingsubstantially the course of the pathology in comparison to both thecontrol animals and the animals treated with bola of cyclophosphamide athigh doses (2×90 mg/Kg ip).

These results prove that bindarit reduces the amount ofimmunosuppressors to be administered with consequent reduction of thosetoxic phenomena that often limit the use thereof in this class ofpathologies.

3. Bindarit and Corticosteroides in Man.

10 patients (8 male and 2 female of from 17 to 60 years old) sufferingfrom lupus nephritis of III and IV class (according to WHOclassification) have been treated with bindarit (600 mg) twice a day andwith prednisone (5 mg twice or trice a day) for 8 weeks.

Before beginning treatment and at the end thereof UAE (Urinary AlbuminExcretion) and interleukine-6 (IL-6) in urine have been measured.

At the end of the study; UAE levels were about 60% of the starting ones.In their turn, the urinary levels of IL-6 were about 10 picograms/mlalso in those patients whose starting levels were 200 and 500picograms/ml.

These results show that bindarit significantly reduces the severity ofnephritis complications occuring in patients suffering from systemiclupus erythematosus treated with corticosteroids.

                  TABLE 1                                                         ______________________________________                                        Bindarit effect on the production                                             of IL-6 induced by concanavaline A                                            treatment      ng/ml    reduction (%)                                         ______________________________________                                        concanavaline A                                                                              16.5 + 6.4                                                     bindarit       10.2 + 2.1                                                                             38.2                                                  ______________________________________                                    

                  TABLE 2                                                         ______________________________________                                        Effects on the median of survival                                                               average increase                                            treatment         (days)  median (days)                                       ______________________________________                                        control           254                                                         cyclophosphamide (22.5)                                                                         259      4                                                  cyclophosphamide (45)                                                                           294     40                                                  cyclophosphamide (90)                                                                           330      76*                                                bindarit          387     133*                                                bindarit +        408     154*                                                cyclophosphamide (22.5)                                                       bindarit +        403     149*                                                cyclophosphamide (45)                                                         ______________________________________                                         *p less than 0.001, KaplanMeier followed by LogRank test                 

                  TABLE 3                                                         ______________________________________                                        Effects on Tmax of proteinuria                                                                  average  p-value                                            treatment         (months) vs. controls*                                      ______________________________________                                        control           7                                                           cyclophosphamide (22.5)                                                                         8        n.s.                                               cyclophosphamide (45)                                                                           9        0.0018                                             cyclophosphamide (90)                                                                           10        0.00006                                           bindarit          9        0.0078                                             bindarit +        9        0.0168                                             cyclophosphamide (22.5)                                                       bindarit +        10        0.00006                                           cyclophosphamide (45)                                                         ______________________________________                                         *Mann-Whitney test with corrections for multiple comparisons             

1. U.S. Pat. No. 5,278,183.

2. Cioli V. et al. J. Rheumatol. 19: 1735-1742, 1992.

We claim:
 1. A pharmaceutical composition comprising synergisticeffective amounts of bindarit, an immunosuppressant and apharmaceutically acceptable excipient.
 2. A pharmaceutical compositionaccording to claim 1, characterized in that said composition containssuch an amount of immunosuppressant to insure an administration level offrom 0.01 to 100 mg/Kg/day.
 3. A composition according to claim 1wherein the immunosuppressant comprises a corticosteroid.
 4. Acomposition according to claim 1 wherein the immunosuppressant comprisesprednisone.
 5. A composition according to claim 1 wherein theimmunosuppressant comprises a cyclophosphamide to insure anadministration level of from 0.01 to 10 mg/kg/day.
 6. A compositionaccording to claim 1 wherein the immunosuppressant comprises prednisonein an amount to insure an administration level of from 0.01 to 1mg/kg/day.
 7. A pharmaceutical composition according to claim 1, whereinthe immunosuppresant is selected from the group consisting of:cyclosporine, azatioprine, methotrexate, cyclophosphamide, FK 506,cortisolo, betametasone, cortisone, desametasone, flunisolide,prednisolone, methylprednisolone, prednisone, triamcinolone,alclometasone, amcinomide desonide and desoxymetasone.
 8. Apharmaceutical composition according to claim 1 wherein said compositioncontains an amount of bindarit to insure an administration level of from1 to 50 mg/Kg/day.